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I once wrote a short book on health scares that suggested that it would be easy to generate a health scare, for example by suggesting that drinking tea was associated with cancer of the stomach. Lo and behold, a refutation of this possibility from the professional association of tea merchants and manufacturers was published in a newspaper soon afterwards.
In like fashion I once suggested satirically that money should be regarded as a treatment for conditions such as alcoholism, since it is well known that drunks, whatever their state of intoxication, can be dissuaded from taking their next drink by the offer of money if they refuse it. Indeed, in such conditions as alcoholism it would be possible to show a true dose-response relationship, the more money paid the more powerful the effect.
My mild satire was soon overtaken by events, as monetary rewards were indeed seriously offered as medical treatment of drug addicts and others. And this week in the New England Journal of Medicine there is a paper that compares the efficacy of various types of monetary bribe to smokers to get them to quit[1].
People were offered different schemes of monetary reward, each valued $800, if they gave up smoking. About six per cent of those who took up the offer were found to be non-smokers in the first place, an interesting estimation of the percentage of the population that is prepared to commit fraud when the opportunity arises and there seems to be no penalty for doing so.
The schemes varied as to whether they straightforwardly offered positive financial reward, or whether they included some penalty for failure, the participants having put down a deposit of $150 unreturnable if they failed to quit. The schemes were also divided into those that were individual and those that provided group incentives.
The results were both encouraging and discouraging. Overall, the rates of smoking cessation at six months were three times higher with monetary incentives than they would have been without, although still not very high. But at twelve months, after the incentives had ceased, the difference had halved. Improvement was not maintained, therefore, but the authors did not go so far as to suggest that further bribes should be offered to recalcitrant smokers. Surely a chronic condition requires chronic treatment?
The scheme in which smokers put down a deposit which they could lose ($150) if they failed, as well as receive a positive reward ($650) if they succeeded, was considerably more effective than the scheme in which they had only $800 to gain. The problem was that a much reduced proportion of smokers was willing to put up the $150 deposit than to enter a scheme in which they had only $800 to gain.
I immediately thought of the implications of this for the tort system: the way to reduce the number of civil actions in the courts is to ensure that every litigant has something to lose by his litigation. This is also in accordance with natural justice.
Group bribes were no more effective than individual bribes. Social pressure to succeed did not increase efficacy, contrary to initial expectation.
For me, what the paper in the NEJM omitted was at least as interesting as what it included: the dog that did not bark in the night, as it were. First, it treated a monetary bribe as morally unproblematic, in precisely the same way as it would have treated a pill or a potion, that is to say as if smoking straightforwardly a disease and money were a straightforwardly pharmacological agent. And it seems to me obvious that if the authors had offered, say, $1 million instead of $800, the results would have been very different. As a bribe to people with a median household income of $60,000, $800 seems to me pathetically, homoeopathically, even insultingly, little. The authors evidently need further training in the art of bribery, perhaps in Nigeria or Albania. Certainly, further studies with different sizes of bribes to smokers are needed.
The authors also did not remark on the difference between behaviour and pathology. You can bribe someone to take his thyroid pills, for example, but you cannot bribe him to stop needing them, to start producing thyroid hormone on his own. This is a distinction that it is worth making, but which we increasingly refuse to make for fear of being, or (what is worse) being accused of being, judgmental. But judgment cannot so easily be avoided: for the supposed need to avoid it is itself based upon a judgment.
[1] N Engl J Med 2015; 372:2108-2117
